W. Va. Code R. § 114-54-2

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-54-2 - Definitions

As used in this legislative rule:

2.1. "Affiliation period" means, with respect to a health maintenance organization, a period that begins on an individual's enrollment date, runs concurrently with any waiting period under the group health plan, expires before coverage is effective and during which the health maintenance organization need not provide medical care and may not charge any premium to the individual.

2.2. "Bona fide association" means an association which:

a. has been organized in good faith for purposes other than that of obtaining or providing insurance;

b. has a minimum of one hundred members;

c. has been actively in existence for at least five years;

d. has a constitution and bylaws providing that:

1. the association holds annual meetings to further purposes of its members;

2. except in the case of credit unions, the association collects dues or solicits contributions from members; and

3. the members have voting privileges and representation on the governing board and committees that exist under the authority of the association;

e. does not condition membership in the association on any health status-related factor relating to an individual;

f. makes accident and sickness insurance offered through the association available to all members regardless of any health status-related factor relating to members or individuals eligible for coverage through a member;

g. does not make accident and sickness insurance coverage offered through the association available other than in connection with a member of the association; and

h. meets any additional requirements as may be set forth in chapter thirty-three of the West Virginia Code or by rule.

2.3. "Commissioner" means the commissioner of insurance.

2.4. "Creditable coverage" means, with respect to an individual, coverage of the individual after June 30, 1996, under any of the following, other than coverage consisting solely of excepted benefits:

a. A group health plan;

b. A health benefit plan;

c. Medicare Part A or Part B, 42 U.S.C. '1395 et seq.; Medicaid, 42 U.S.C. '1396a et seq. (other than coverage consisting solely of benefits under section 1928 of the Social Security Act); Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), 10 U.S.C., Chapter 55; and a medical care program of the Indian Health Service or of a tribal organization;

d. A public health plan or a health benefits risk pool sponsored by any state of the United States or by the District of Columbia, as defined in regulations promulgated by the federal Secretary of Health and Human Services; a health plan offered under 5 U.S.C., chapter 89; or a health benefit plan as defined in the Peace Corps Act, 22 U.S.C. '2504(e).

2.5. "Days of creditable coverage" means the aggregate of the periods of creditable coverage, as defined in section 2701(a)(3) of the Public Health Service Act.

2.6. "Dependent" means an eligible employee's spouse or any unmarried child or stepchild under the age of eighteen or unmarried, dependent child or stepchild under age (23) twenty-three if a full-time student at an accredited school.

2.7. "Eligible employee" means an employee, including an individual who either works or resides in this state, who meets all requirements for enrollment in a health benefit plan.

2.8. "Employer" means a large employer or a small employer. In connection with a partnership to which this rule applies, employer includes the partnership in relation to any partner, and in connection with a health benefit plan issued through one or more bona fide associations, "employer" includes a bona fide association acting as policyholder for the employers.

2.9. "Enrollment date" means an individual's first day of coverage under a group health plan or, if there is a waiting period, the first day of the waiting period.

2.10. "Excepted benefits" means:

a. Any policy of liability insurance or contract supplemental thereto; coverage only for accident or disability income insurance or any combination thereof; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; workers' compensation insurance; or other similar insurance under which benefits for medical care are secondary or incidental to other insurance benefits;

b. If offered separately or otherwise not as an integral part of a health benefit plan or the group health plan in connection with which it is issued, a policy providing benefits for long-term care, nursing home care, home health care, community-based care or any combination thereof, dental or vision benefits, or other similar, limited benefits;

c. If offered as independent, noncoordinated benefits under separate policies or certificates, specified disease or illness coverage, hospital indemnity or other fixed indemnity insurance, or coverage, such as Medicare supplement insurance, supplemental to a group health plan; or

d. A policy of accident and sickness insurance covering a period of less than one year.

2.11. "Group health plan" means an employee welfare benefit plan, including a church plan or a governmental plan, all as defined in section three of the Employee Retirement Income Security Act of 1974, 29 U.S.C. '1002, to the extent that the plan provides medical care. For purposes of this rule, "group health plan" includes any plan, fund or program which would not (but for this subsection) be a group health plan and which is established or maintained by a partnership, to the extent that such plan, fund or program provides medical care to present or former partners or their dependents (as defined under terms of the plan, fund or program).

2.12. "Health benefit plan" means benefits consisting of medical care provided directly, through insurance or reimbursement, or indirectly, including items and services paid for as medical care, under any hospital or medical expense incurred policy or certificate; hospital, medical or health service corporation contract; health maintenance organization contract; or plan provided by a multiple-employer trust or a multiple-employer welfare arrangement. "Health benefit plan" does not include excepted benefits.

2.13. "Health insurer" means an entity licensed by the commissioner to transact accident and sickness insurance in this state and subject to chapter thirty-three of the West Virginia Code. "Health insurer" does not include a group health plan.

2.14. "Health status-related factor" means an individual's health status, medical condition (including both physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence) or disability.

2.15. "Large employer" means any person, firm, corporation, partnership or bona fide association actively engaged in business in the state of West Virginia who employed an average of at least fifty-one (51) eligible employees on business days during the preceding calendar year and employs at least two employees on the first day of its group health plan year.

2.16. "Late enrollee" means an individual, other than one who enrolls during a special enrollment period, who enrolls under a health benefit plan or a group health plan in connection with which it is issued other than during the first period in which the individual is eligible to enroll under terms of the health benefit plan or group health plan.

2.17."Medical care" means amounts paid for, or paid for insurance covering, the diagnosis, cure, mitigation, treatment or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body, including amounts paid for transportation primarily for and essential to such care.

2.18. "Medical care provider" means an individual licensed or similarly authorized to provide medical care and operating within the scope of services authorized for the individual.

2.19. "Network plan" means a health benefit plan under which the financing and delivery of medical care are provided, in whole or in part, through a defined set of providers under contract with the health insurer. Network plans include, but are not limited to, health maintenance organizations and preferred provider arrangements.

2.20. "Policyholder" means the group health plan sponsor, as defined in section three of the Employee Retirement Income Security Act of 1974, 29 U.S.C. '1002.

2.21. "Preexisting condition exclusion" means, with respect to a health benefit plan, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the enrollment date for such coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before the enrollment date.

2.22. "Significant break in coverage" means a period of sixty-three consecutive days during all of which an individual does not have any creditable coverage, except that neither a waiting period nor an affiliation period is taken into account in determining a significant break in coverage.

2.23. "Small employer" means any person, firm, corporation, partnership or bona fide association actively engaged in business in the state of West Virginia who, during the preceding calendar year, employed an average of no more than fifty but not fewer than two eligible employees and employs at least two employees on the first day of its group health plan year. A new employer, not in existence for all of the preceding calendar year, shall be considered a small employer if it is reasonably expected to employ an average of no more than fifty but not fewer than two eligible employees on business days in the current calendar year. Companies which are affiliated companies or which are eligible to file a combined tax return for state tax purposes shall be considered one employer.

2.24. "Special enrollment period" means a period other than the first period in which an eligible employee or a dependent is eligible to enroll under the terms of a health benefit plan or a group health plan in connection with which it is issued, without regard to other enrollment periods defined under the health benefit plan or group health plan.

2.25. "Waiting period" means, with respect to a group health plan and an eligible employee or a dependent who is potentially eligible for coverage under the plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan.

W. Va. Code R. § 114-54-2